TAVI in centers without on-site cardiac surgery. Need or dare?

Since its incorporation into routine clinical practice more than 20 years ago, transcatheter aortic valve implantation (TAVI) has progressively gained acceptance within the cardiology community, driven by a successful and comprehensive clinical program that began with early reports in inoperable1 and high-risk patients,2 around 2010. From the earliest studies, patient eligibility for TAVI was determined by a multidisciplinary committee of cardiologists and surgeons— which came to be known as the heart team—and procedures were performed exclusively at centers with on-site cardiac surgery. Similarly, all subsequent clinical practice guidelines on the management of TAVI have assigned the highest level of recommendation to performing the procedure in centers with a heart team and on-site cardiac surgery, a requirement that has persisted through the most recent European clinical practice guidelines.3 On the other hand, the marked increase in the number of procedures is making it difficult for hospitals with on-site cardiac surgery to meet this growing demand, thereby considerably prolonging waiting times—an especially sensitive issue given the high mortality rate of patients in this situation, which may exceed 15%.4 Therefore, it may be time to ask the following question: is the presence of a cardiac surgery department at the center still a prerequisite for establishing...